Triage Regulations

[medic182]

I am trying to find information about triage regulations in the state of PA or anywhere really and I am unable to find anything concrete. Here is the situation our ER is in. We are a small community ER (11 beds), see an average of 70 patient's per day. Our previous process was this. A patient would come in the waiting room, sign in at the triage desk. The triage nurse would take there slip and give it to registration (on the other side of the waiting room) registration would register teh patient, the triage nurse would take the patient back to a room and finish their triage at bedside. (just to note, every single patient that comes into our ER, even a simple laceration, has to have a total of 11 pages of paperwork filled out including an entire database prior to the nurse or physician seeing them.) the triage nurse would hten go back out to their office and wait for the next patient and start over. If someone signed in with chest pain, SOB, CVA, etc they were brought right back, and registration was also completed at bedside. This process actually worked really well for our ER. Here is the problem. Senior adminsitration is now sayign that the triage nurse is not allowed to leave their office at all and then all paperwork should be completed at the bedside by the primary nurse. Senior administration is saying it is a law that the triage nurse is not allowed to leave the office and that the first person the patient is the triage RN. The only thing I can find is the EMTALA regulations that state a medical screenign exam has to be preformed prior to discharge, leaving AMA, or transfer, nothing that regulates the traige process. Any help would be great.

Thanks

[BrnEyedGirl, BSN, MSN, RN, APRN]

I work in a much larger ER,..but our triage nurses are not allowed to leave the triage area. We are to be the first one to see the pt, even if it's just a quick look at them and to hear the C/O. We use computerized charting and the triage is done in a triage room, given an acuity then either palced in a bed or the waiting room. We usually have two RN's, a tech and registration at triage. Of course if someone comes in really in distress, they are taken right back and triaged at bedside. Hope that helps. I'm of the understanding that this is ENA regulations.

[Lunah, MSN, RN]

Senior adminsitration is now sayign that the triage nurse is not allowed to leave their office at all and then all paperwork should be completed at the bedside by the primary nurse. Senior administration is saying it is a law that the triage nurse is not allowed to leave the office and that the first person the patient is the triage RN.

I would ask for senior administration to show me this "law" -- you know, just so I could be compliant and all. I doubt it's a "law."

[nursein08]

I work at a busy ER in Pa and do triage. I've never heard of this law. Working the 7p-7a shift, we go down to just the triage nurse in the triage area at 11p. That means to bring a pt back we need to leave the triage area. I think your senior admin is feeding you a line. If there is a law I sure would like to see it to show mgmt.

[Larry77, RN]

JACHO was huge on this a few years ago...made us change the way we did it too...the whole point is for the RN to be the first one to see the patient--not registration or support staff. I'm not sure about a "law" but was definitely a hot topic.

[canoehead, BSN, RN]

I don't think it's a law, but they can make it hospital policy. So if a patient needs to be taken right back does the triage nurse wait for the charge to assign someone, that someone to be free, and come out to get the patient from triage? Does the triage nurse get to use the bathroom between breaks, or do they need someone to cover them?

The triage nurse generally stays in the triage area just because anything can come in the door, but getting to strict with that may cause problems they don't anticipate. It also seems fairly heavy handed. As does the 11 page assessment. Is the patient required to answer the 11 pages of questions before they get O2, or can you defer until they are somewhat stable.

[Kowens]

I work in a large inner city hospital in PA and have done some research in the area of different triage methods...ESI 4 vs. 5 level...no where in my lit reviews have I seen any mention of a law about RN seeing the patient first as a law. When we have been short staffed, management has placed technicians in triage(which I did not agree with) and they obtained basic complaints and vital signs and then the charge nurse would place them in a room. I am sure that "laws" ie a new hospital policy can come about for many reasons. Has anything occurred in the department, maybe a missed MI or CVA onset or something that could have prompted this change in policy. Always a reason why..just might not agree with it but has to be a reason.

I feel that a nurse should be the first to identify the patient, atlease do your 3 second assessment, you can look at a patient and tell if they need assistance before the hang nail patient that is screaming to be seen now!!! :)

[pyegirlrn]

I work in a small rural hospital in GA with 3 fast-track beds and 9 ER beds. There is a small triage area with one nurse and no tech. There are 2 registrars next to the waiting area who obtain the initial complaint and registration information. Then they call over the intercom for the triage nurse.

After the all the triages are completed, it is the expectation that the triage nurse will come back and help the other nurses to discharge and care for their patient. She just hopes that she can break loose to go to the triage area. My concern is that there may be legal liability in leaving my triage post. Another concern is that I feel that the triage position is not respected and no matter what you help the nurses do it is never enough. Please advise. Any feedback would be appreciated.

[Altra, BSN, RN]

pyegirlrn, the potential problem I see in your scenario is that if the registration folks are obtaining registration (read: financial) information from the patient prior to triage, that can be interpreted as an EMTALA violation. And how much does that process throw off certain key standards of care, such as an EKG within 10 minutes of presentation for a patient with chest pain?

I'm not sure what to say about the perceived lack of respect for triage where you work. In my experience (in larger ERs with one or even two dedicated triage nurses at all times) the nurses assigned to triage are those with at least 1-2 years of ER experience, trusted by both nursing management and the physicians to ask the right questions and make the right decisions to ensure that no one dies in the waiting room, all the while fending off the Evil Eye Glare from the waiting room.

[BrnEyedGirl, BSN, MSN, RN, APRN]

Another issue that occurs when the nurse isn't the first to see the pt is that the L arm pain is an MI or the R hand is tingling is a stroke,....registration can't be responsible to identify this!

Our registration only places the pt in the computer and assigns a med record number,...all insurance information is gathered/verified after the pt is in a room and has seen a doc!

I agree with you Altra, our triage nurses must have a minimum of one year ER experience and complete a triage course. We do EKG's at triage and have staff to take pt's back to a room. A great system we have in place is a communications nurse. This nurse takes all radio reports and places all pt in a bed. The triage nurse and the comms nurse communicate to decide who goes back when and to what room,.for instance if a belly pain needs a pelvic bed or an eye pain needs the eye room, or even which of the 27 3's in the waiting room should go first! We usually have 2 RN's, a tech, and registration at triage, and on good days we have volunteers and transport staff to take pt to rooms.

[Anna Flaxis, BSN, RN]

I agree with Altra, I think triage should occur prior to registration. I can sort of understand the reasoning for having a triage nurse in triage at all times. You never know what is going to come through the door. Have they at least implemented some sort of flow system, such as having a second nurse who rooms patients, or can you call the charge when you have a 2 that needs a room STAT? If you can't leave triage, then *somebody* has to be available to get the 2s back and get them started and then hand them off to the primary. Also, you need to be covered for your breaks. As long as they've addressed those issues effectively, then I don't see why it's a problem to be in triage at all times.

[traumajunkie63]

triage should occur prior to registration...where i work now, infact, registration is the last thing to be performed so that there is no question about fair medical practice. They feel that if the ER MD know they do not have insurance they will treat them diffrent or give them a diffrent kind of medicine..HOWEVER, TRIAGE SHOULD BE DONE PRIOR TO THE ER NURSE IN BACK SEEING..this is why it is called TRIAGE..this is how you chart your accuity and level of care. I agree with the throughput of get the patients back as soon as you can..they are here to see the ERMD, not the nurse, but they should at least have the first set of vital done and a small blurb about why they are there...yes we have a second hurse to room patients and that is ok... but have the basics done please